Transgender kids have become the latest target of the far right’s moral ire. Last year, Arkansas became the first state to make it a felony for doctors to provide gender-affirming care—which can include puberty blockers, hormone therapy, and surgery—for transgender children. Alabama followed suit in April, and at least 13 states are considering similar bills. While most bills go after doctors, others would penalize parents for seeking care for their children.
Introduced last year during the 87th Texas legislative session, Senate Bill 1646 would have categorized providing such care to minors as child abuse, but the measure failed to become law. Nevertheless, in February, Attorney General Ken Paxton wrote an opinion categorizing all gender-affirming care for minors as child abuse. Texas Governor Greg Abbott then ordered the Texas Department of Family and Protective Services to investigate parents seeking gender-affirming care for their children, prompting several employees to resign in protest. Now, the Texas Supreme Court is considering whether Abbott had the authority to call for the investigations after three district courts issued injunctions.
Proponents of the investigations claim that gender-affirming treatments are harmful to children. But major medical associations, like the American Medical Association, the American Psychiatric Association, the American Academy of Pediatricians, and the American Academy of Child and Adolescent Psychiatry assert that gender-affirming care is a necessary treatment for dysphoria. These are among the dozens of medical groups that have signed on to amicus briefs supporting lawsuits filed to combat these bills, including the Texas case pending against Abbott. The Texas Observer spoke with licensed physician Colton St. Amand, a gender therapy specialist who identifies as transgender, and psychologist Cesar A. Gonzalez of the Mayo Clinic about the necessity of gender-affirming care for transgender minors and the potential mental health consequences of depriving them of it.
Their responses have been edited for length and clarity.
Why is Gender-Affirming care crucial for minors? Why not wait?
Dr. St. Amand: Gender-affirming care is critical for transgender patients of all ages. We know now from decades of clinical practice, and now over the last couple of decades of research, that the earlier that we affirm someone, the better outcomes they have in terms of mental health and physical health. We found that people generally do really well with treatment. Gender-affirming care is life-saving. This is a population that has high rates of risk for self-harm, suicidal ideation, and suicide attempts, as well as other disparities due to negative responses by the environment—discrimination at school, and rejection from family. All of these variables put this population at risk.
Gonzalez: Not everyone’s going to need some of the biomedical interventions. Psychological and social and even legal interventions may just be as important as biomedical interventions.
For example, we know that name change and gender marker changes are associated with better health outcomes longitudinally. We also know that, psychologically, home environments that are gender-affirming are critical to preventing and actually protecting against suicidal ideation. We know that gender-affirming care not only impacts mental health but also impacts physical health. I think that’s really why gender-affirming care is crucial for trans youth, because it sets them up to have a healthy and quality life in adulthood.
How does receiving gender-affirming care affect the lives of trans kids?
Dr. St. Amand: I’ve seen kids whose parents would tell me [before treatment] that they’ve been depressed for years, not engaging in their life, only kind of on the computer, in their room most of the time, not engaging in school, not making friends. Parents tell me, “I haven’t seen my kids smile in years.”
And when they come [back to] see us, and they’re affirmed in whichever ways are appropriate for the patient—whether that’s a name change, whether that’s pubertal suppression and hormone therapy, whether that’s getting connected with other transgender people to feel more accepted—they smile and they do well. We see improvements academically; we see improvements in mood; we see improvements in anxiety; we see improvements in self-esteem—all very critical for adolescents as they are developing. We see some more engagement with friends and family as well. They just shine. It’s a tribute to when somebody is able to live as their full authentic self.
If the state were to outlaw gender-affirming care, what are the risk factors of completely stopping treatment?
Dr. St. Amand: I think not only are there clear mental-health risks associated with stopping medically necessary treatment but of course, also physical health risks. If they have a puberty blocker in their arm, we generally don’t keep those for more than two years because they’ll need hormones in order for their bone health to be protected. But if they’re not able to access hormone therapy, and they still have puberty-suppressing treatment in them, they’re at risk for early osteoporosis.
Or let’s say that they were taking estrogen and their body is trying to increase their testosterone and the estrogen is suddenly taken away. They can start getting a deeper voice, hair on the face, and other pubertal changes you would associate with male puberty. This can be life-threatening for the young person. All of the changes that we talked about can go away: less family engagement, less school engagement, increased issues with mood anxiety, low self-esteem, and medical distrust, distrust of systems that are supposed to be there to take care of you.
I think all of that is already happening.
Gonzalez: People aren’t going to flourish because they’re going to feel that no one else understands them, or that their identity isn’t really being supported. It’s going to lead to more concealment, and essentially, more minority stress. Minority stress is a really big component of what the individuals deal with but also families deal with. It’s this reinforcement of any experiences of prejudice, discrimination, and violence.
And then, of course, there are other stressors that are these internal feelings or belief systems: “Other people are going to reject me,” or “Other people aren’t going to like me, because if the government or these policymakers, you know, don’t support me, so what does that mean for me?”
We have to think about this in terms of disenfranchisement. Who is most disenfranchised here? It’s going to be people who are of lower socioeconomic status, who can’t afford to move to another state. It’s going to be individuals who already experience day-to-day stress. This additional stress puts an additional burden on their health, leading ultimately to increased risk for a variety of different conditions through inflammation, stress responses, and non-engagement in the healthcare system.
The cascade of consequences isn’t solely on the individual, but on family, communities, and ultimately, populations.
What are the families you are consulting with feeling at this moment?
Dr. St. Amand: In 2019, they started to use some political rhetoric saying “child abuse” and associating that somehow with gender-affirming care, which is the furthest thing from the truth. It’s medically necessary care. Not doing it is actually neglect. I’m currently getting emails now from families that I saw several years ago, before I started my residency, asking, “What should I do? Should we leave the state?” You know, very big, big questions. “Is my child going to be safe? Can they take my child away? I know this was the right thing for my child. But, what do I do?” There are high levels of anxiety and political distrust and worries for the safety of the young person.
How are you advising them to deal with what’s happening now?
Gonzalez: I work with our adolescents and their families to focus on what is actionable, what is controllable, and that is going to be reducing some of the checking of media or websites to see if there are any updates, really trying to create as much sense of stability for the individual. In some ways, that’s helping them live in the moment, giving them the skills to emotionally regulate so that they can fall asleep and not activate stress responses, which then perpetuate distress and anxiety and also physical harms. And so that’s a lot of skill-building and coping.
